Healthcare Provider Details

I. General information

NPI: 1760693535
Provider Name (Legal Business Name): TRILLIUM MEDICAL GROUP OF FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21827 STATE ROAD 54
LUTZ FL
33549-6924
US

IV. Provider business mailing address

PO BOX 23788
TAMPA FL
33623-3788
US

V. Phone/Fax

Practice location:
  • Phone: 727-750-8103
  • Fax: 866-788-0863
Mailing address:
  • Phone: 800-750-8103
  • Fax: 866-788-0863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BOBBY L COATES
Title or Position: PRESIDENT
Credential:
Phone: 727-403-5221